Kittery School District Early Childhood Intake Questionnaire
Upon receipt of the questionnaire and required documentation, the district will reach out to schedule a meeting to consider options to support your child. 
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Student Registration Information
Child's Name  *
Child's Date of Birth *
Child's Gender *
(1) Name of Parent or Guardian: *
(1) Physical Address (not a PO Box)
Street, City, State and Zipcode
 *
(1) Mailing Address, if different

(1) Telephone: *
(1) Email Address: *
(2) Name of Parent or Guardian: *
(2) Physical Address (not a PO Box)
Street, City, State and Zipcode
 *
(2) Mailing Address, if different:
(2) Telephone: *
(2) Email address: *
Who does the child live with?

Both parents have legal rights to receive information about their child unless otherwise ordered by the courts. Court documentation must be submitted to the schools if information should not be shared.
 *
Other members of Household; please include siblings and their ages: *
Please use the linked table from the  USDA Income Eligibility Guidelines, as guidance to determine your student's economic status. If household income is less than the Annual or Monthly earnings for your household size in the charts, then your student meets the economic disadvantaged status criteria. Household size includes adults and children.  
Mark only one oval.
 *

Dear Parent/Guardian:

Maine welcomes families of all cultural and linguistic backgrounds. Speaking more than one language is a valuable asset, and we encourage families to maintain their languages while learning English. Students who speak or understand another language may be entitled to support to improve their English in order to meet Maine's challenging academic standards. The following questions, required for all students from pre-kindergarten through grade 12, will help your school determine whether your child may benefit from English language support services.

If a language other than English is indicated, your child will be administered an English language screener.Depending on your child's score, your child may be classified as an English Learner and eligible for English language support.If you would like this letter and the survey below to be provided in another language, or if you would like an interpreter, your school will fulfill those requests.
If you have questions about this survey, please contact your school principal.

Be assured that your answers will be used only for educational purposes. The completed survey will be kept in your child's permanent file, and only school staff will have access to it. No school employee may inquire about the immigration status of any member of your family.

Thank you for providing this information, and I wish your student great academic success.

Sincerely,
April Perkins
Director of ESOL and Bilingual Programs, Maine Department of Education



If other languages are spoken at home, what are they? Please write N/A if not applicable. 

 *
What language(s) does your child most easily speak or understand? *
What language(s) did your child first speak or understand? *
What language(s) do people use with your child daily? *
Child's Ethnicity/Race
Mark all that apply
 *
Required
Are either parent/guardian of the child an active member of the military?

 *
Required
Are either parent/guardian of the child a civilian employed on government property?
Mark only one oval.
 *
Do you agree to receive documents electronically? *
Medical History
Child's Primary Care Physician *
Primary Care Provider Facility/Address and Phone Number *
Where was your child born?
Please indicate Country, City and State.
 *
Prenatal and Birth History (Please check all that apply) *
Required
Comments on prenatal or birth history:
Past Medical History:
Check all that apply
 *
Required
If your child has allergies, please list them and the typical reaction to the allergen:
Please list the medications your child is taking: *
Comments on past medical history: *
Has your child ever had any of the following evaluations or assessments:
Check all that apply.
 *
Required
Has your child received any of the following services?
Check all that apply.
 *
Required
Please check any of the following that your are currently involved with:
Check all that apply.
 *
Required
Has your child ever received a medical diagnosis? *
Are there any hearing concerns? *
Does your child wear hearing aids or cochlear implants?
Mark only one oval.
 *
Are there any vision concerns? *
Does your child wear glasses?
Mark only one oval.
 *
Does your child attend childcare or preschool?
Mark only one oval.
 *
If your child attends a childcare or preschool program, where do they go and what is their schedule?
How would you describe your child (Please check all that apply): *
Required
Developmental Milestones
Please indicate whether your child has met the following developmental milestones:
Roll over (4-6 months):
Mark only one oval.
 *
Crawl (7-12 months)
Mark only one oval.
 *
Sit independently (4-7 months)
Mark only one oval.
 *
Walk (11-18 months)
Mark only one oval.
 *
Pick up small objects (8-12 months)
Mark only one oval.
 *
Follow Directions (12-24 months)
Mark only one oval.
 *
Points (12-18 months)
Mark only one oval.
 *
Puts words together (18-24 months)
Mark only one oval.
 *
Hold a spoon (8-12 months)
Mark only one oval.
 *
Scribble (18-24 months)
Mark only one oval.
 *
How does your child communicate?
Check all that apply.

 *
Required
How much of what your child says do you (a familiar communication partner) understand?
Mark only one oval.
 *
Do unfamiliar communication partners understand your child?
Mark only one oval.
 *
Communication Concerns
Check all that apply.
 *
Required
Do you have gross motor concerns? *
Do you have fine motor concerns? *
Do you have concerns about feeding? *
Do you have concerns about academic readiness? *
Behavior History
Do you have any concerns about your child's behavior? *
Does your childcare/preschool have any concerns about your child's behavior? *
Has your child experienced any of the following major changes in his/her life?
Please check all that apply.
 *
Required
Comments on child's behavior:
My child stays interested in self chosen activities for:
Mark only one oval.
 *
My child separates easily from a parent:
Mark only one oval.
 *
My child takes care of bathroom needs independently:
Mark only one oval.
 *
My child enjoys playing alone:
Mark only one oval.
 *
My child enjoys playing with children his/her own age:
Mark only one oval.
 *
Is there any other information that would help us to understand and support your child at this time?
Please contact Sarah Lane at the Kittery School District to make an appointment to provide the following documents required to process this request. When documents have been processed, an initial meeting will be scheduled to determine if evaluations should be completed to support possible programming to support your child. 

-2 Proofs of Residency
-Original Birth Certificate

“Residency” is defined as the actual residence in the Town where a person ordinarily and primarily sleeps, has meals, and conducts leisure activities throughout the school year more than 50% of the time. Any person can be a resident of only one location at any given time.

Ownership or rental of property alone does not establish residency.  Evidence of residency may include address on driver’s license, registration of vehicles, voter registration, where a homestead exemption is claimed, mailing address, legal residence as stated on State and Federal tax returns, and days per week and weeks per year that parent(s) or guardian(s) is domiciled in the Town, but these individual factors will not control if the weight of evidence does not establish residency as defined above.


Sarah Lane, Kittery School District

200 Rogers Rd, Kittery, ME 03904

(207) 475-1334
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